Are white coats going out of fashion?

Do white coats still have a place in modern medicine as we practise it today? Iqbal Naveed Khan thinks so

Over the years, the white coat has become an item of clothing symbolising doctors and other medical personnel. Indeed, the website of a London medical school describes that "despite all the challenges the thrill of the white coat never leaves you."^w1 Doctors are often seen in white coats in television programmes, and the dress is often used as a means to distinguish doctors from other people. White coats have become something of a symbol of hygiene and authority, but should they really be used in modern medicine?^w2

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The white coat has been worn since the 19th century; its main purpose is to prevent cross contamination .^w2 Since then, however, the symbolic value of the white coat has increased. It seems that the white coat generally stands for authority and professionalism."White coat" ceremonies in the United States welcome new students into medical school.^w3 The families and friends of new medical students attend, and students are given white coats before the start of their course. However, opinions differ on the symbolic-and hygienic-value of the white coat in the practice of medicine today.

The most obvious advantage of doctors wearing white coats is that they stand out among others in a busy hospital, which can help avoid confusion.^w4 This theory is supported by a survey in which a significant number of people said that white coats made it easier to identify doctors.^w5 Among the 276 patients and 86 doctors, the popularity of white coats was much higher (almost double) amongst patients than medics, with some people holding the view that they pose a risk of infection.^w4

Attitudes towards white coats also seem to vary with age. One study showed that"there was a significant increase in the demand for a white coat with increasing age of the patients."^w6 And a survey done at the Royal Free Hospital also showed similar trends: patients aged at least 70 years were most in favour of white coats, and patients aged 30-39 years were least so.^w7 The age specific difference in attitudes towards white coats indicates that the popularity of white coats is declining. There is a similar pattern in the views of doctors: older doctors and doctors from some specialties, such as surgery and obstetrics and gynaecology, prefer the white coat.^w5 Another interesting finding from the same survey is that about 50% of the doctors who believed that white coats ought to be worn did not actually wear white coats themselves.^w4

White coats also have other benefits related to the image of doctors and the level of confidence the public has in the medical profession. Valerie Jones of Columbia University College of Physicians and Surgeons suggests that the white coat"Reminds physicians of their professional duties, as prescribed by Hippocrates, to lead their lives and practise their art in uprightness and honor"^w8 This is understandable because white is a colour that traditionally symbolises chastity and cleanliness. Although some may argue that this image has been dented in recent years, with stories such as that of Harold Shipman. But doctors are still rated as among the most trustworthy of people-91% of people believe that doctors generally tell the truth.^w9

Several arguments against doctors wearing white coats have also been put forward, however. Dr Ayan Panja, who works in general practice, argued that the white coat can"act as a communication barrier between doctors and patients." This seems a valid point because the white coat creates a visible difference between a doctor and a patient, which could decrease the openness between the doctor and patient in a consultation. Dr Panja goes on to ask whether there is"something intrinsically authoritarian, even intimidating, about such a uniform."^w2

More obvious reasons may deter doctors from wearing white coats, such as comfort and convenience. The Royal Free Hospital's survey found that six out of 10 people found white coats"too hot and uncomfortable."^w4 You can imagine how difficult it must be to examine patients and carry out procedures, sometimes while kneeling, while wearing a long white coat.

People wanting to impersonate medical personnel can also exploit the symbolic value of the white coat. In one case, a member of the public spotted a school pupil who was seated in front of radiographs that were clearly marked with the patients' names-a situation that appears to clearly breach patient confidentiality.^w10 Although this is not a case of a deliberate attempt to impersonate a doctor it did raise concerns. The member of the public said she was horrified and thought it totally unacceptable in the NHS.^w10 Although the decision to allow students to shadow doctors in hospitals was defended by a local emergency consultant, some people may still have concerns about impersonation, which could have negative implications for the doctor-patient relationship.

The above arguments are relevant, but the most important matter is whether white coats maintain high levels of hygiene and sanitation. Historically doctors wore white coats because they were seen as an effective barrier against the spread of disease.^w2 But more recent studies contradict this-for example, a recent study showed that a quarter of white coats worn by doctors in a general hospital were contaminated with Staphylococcus aureus.^w2 This is understandable because white coats tend not to be changed or cleaned very often and hence provide a medium where bacteria can multiply. Other clothes worn by doctors, such as shirts and ties, tend to be changed more often. For this reason some doctors prefer scrubs-John Heyworth, an emergency doctor at Southampton General Hospital, aired just such a view on the BBC. He believes that scrubs are"easy to wash-which is important as patients tend to bleed, vomit, and do other unspeakable things over doctors."

1. http://www.qmul.ac.uk/courses/department.php?dept_id=17&article_id=38 Queen Mary, University of London
2. Ayan Panja, senior registrar, general practice 2004;328:57 (3 January), doi:10.1136/bmj.328.7430.57 The death of the white coat?
3. William T. Branch Jr., MD 01/11/1998 Volume 129 Issue 9 Pages 740-742. Deconstructing the White Coat. Annals of Internal Medicine
4. http://news.bbc.co.uk/1/hi/health/3706783.stm 13/05/2004 Doctors ‘should wear white coats’
5. Douse J, Derrett-Smith E, Dheda K, Dilworth JP. Should doctors w ear white coats? Postgrad Med J. 2004 May;80(943):284-6.
6. Anvik T. 1990 Jul;8(2):91-4. Doctors in a white coat--what do patients think and what do doctors do? Scand J Prim Health Care
7. Fiona Harvey 14/05/2004 Doctor’s white coat polarises opinion http://www.ucl.ac.uk/news-archive/in-the-news/2004/may-2004/latest/newsitem.shtml?itnmay0407
8. Valerie A. Jones, Columbia University College of Physicians and Surgeons. 1999;281:478 Medical Student Jama The White Coat: Why not Follow Suit?
9. http://news.bbc.co.uk/1/hi/health/1829590.stm 19/02/2002 ‘Public still trust doctors’
10. Marjory Inglis 16/10/2004 Pupil ‘impersonating’ doctor sparks anger The Courier

       

           

	LIFE Are white coats going out of fashion?        Iqbal Naveed Khan - March 2007
	Maya Gopalakrishnan (February 25th, 2007)        Third year medical student, Pondicherry,India maya.gopalakrishnan@gmail.com
	This article rightly points out the attitudes of young doctors towards the white coat tradition especially with respect to comfort and concerns about spread of infections.Indeed some recent studies do indicate a variety of microflora on the coats of doctors and medical students(Loh W,Ng VV,Holton J. J Hosp Infect. 2000 May;45(1):65-8).This might have an easy solution in regular cleaning and laundering of the coat as it is also pointed out that the contamination often correlated with how clean the student estimated the coat to be! However the contention that the white coat may prove to be a communication barrier because of a "visible difference" seems meaningless in this context as I believe that the white coat acts as an aid to communication as it increases the confidence of the patient in the doctor.The "visible difference" in itself is a source of comfort to the patient believing that the "doctor" can do something for their state of distress. Considering these I strongly believe that the white coat has a long way before they go out of fashion.